Provider Demographics
NPI:1548526866
Name:GREEN, TITA MARIE (MS)
Entity type:Individual
Prefix:
First Name:TITA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2079
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1017
Mailing Address - Country:US
Mailing Address - Phone:678-396-2279
Mailing Address - Fax:678-945-7713
Practice Address - Street 1:707 WHITLOCK AVE SW
Practice Address - Street 2:SUITE H-11
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3000
Practice Address - Country:US
Practice Address - Phone:678-396-2279
Practice Address - Fax:678-945-7713
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006928101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional